The benchmark analysis of gastric, colorectal and rectal cancer pathways: toward establishing standardized clinical pathway in the cancer care.

Most clinical pathways in treating cancers in Japan are based on individual physician's personal experiences rather than on an empirical analysis of clinical data such as benchmark comparison with other hospitals. Therefore, these pathways are far from being standardized. By comparing detailed clinical data from five cancer centers, we have observed various differences among hospitals. By conducting benchmark analyses, providing detailed feedback to the participating hospitals and by repeating the benchmark a year later, we strive to develop more standardized clinical pathways for the treatment of cancers. The Cancer Quality Initiative was launched in 2007 by five cancer centers. Using diagnosis procedure combination data, the member hospitals benchmarked their pre-operative and post-operative length of stays, the duration of antibiotics administrations and the post-operative fasting duration for gastric, colon and rectal cancers. The benchmark was conducted by disclosing hospital identities and performed using 2007 and 2008 data. In the 2007 benchmark, substantial differences were shown among five hospitals in the treatment of gastric, colon and rectal cancers. After providing the 2007 results to the participating hospitals and organizing several brainstorming discussions, significant improvements were observed in the 2008 data study. The benchmark analysis of clinical data is extremely useful in promoting more standardized care and, thus in improving the quality of cancer treatment in Japan. By repeating the benchmark analyses, we can offer truly clinical evidence-based higher quality standardized cancer treatment to our patients.

Multicenter randomized comparison of LigaSure versus conventional surgery for gastrointestinal carcinoma.

PURPOSE: We conducted this randomized trial to compare the LigaSure Vessel Sealing System with conventional methods in gastrointestinal carcinoma surgery at five specialty cancer hospitals. METHODS: Patients with resectable stomach or colorectal cancers were randomized to the LigaSure (n = 100) or conventional surgery (n = 74) groups according to sealed envelopes. The operative data were compared. RESULTS: There were no significant differences in operating times, blood loss, postoperative complications, or hospital stay. However, at the hospital where most of the procedures took place, the LigaSure was associated with a shorter operating time (173 ± 43 min for gastric carcinoma and 157 ± 43 min for colorectal carcinoma vs 211 ± 55 min and 202 ± 55 min for conventional surgery; P = 0.0046 and P = 0.0200, respectively) and less blood loss (300 ± 196 ml and 150 ± 133 ml, respectively, vs 453 ± 387 ml and 382 ± 444 ml; P = 0.0482 and P = 0.0465, respectively). CONCLUSIONS: The LigaSure is safe for both gastric and colorectal cancer surgery with extended lymph node dissection. Used effectively, the device appears to reduce operating times and blood loss, although this requires confirmation in a larger series.

Portal vein branching pattern in anomalous right-sided round ligament.

OBJECTIVE: To study the relationship of anomalous right-sided round ligament with respect to branches of the portal vein. METHODS: We studied four patients of right-sided round ligament diagnosed radiologically in the last 5 years. 3-D volume rendered CECT abdominal images were analyzed for attachment of the round ligament in the liver in relation to portal venous anatomy and position of gallbladder. RESULTS: In all cases, a trifurcate pattern of portal venous branching was observed. Right-sided round ligament was attached at the point of divergence of the right anterior portal vein. The region to the left of the point of its attachment drained into the middle hepatic vein while the region to the right of the point of attachment drained into the right hepatic vein. The left portal vein branched into posterior and paramedian branches. Right, middle, and left hepatic veins were visualized having normal course in all cases. In all, the gallbladder was present to the left of the round ligament. CONCLUSIONS: Trifurcate pattern of portal vein branching in all four cases. Right-sided round ligament was attached to the bifurcation of the right anterior portal vein in all the cases. The left portal vein branched into posterior and paramedian branches.

Hepatic hilar resection for hilar cholangiocarcinoma based on a reclassification.

Major hepatic resection for hilar cholangiocarcinoma is reportedly closely associated with severe postoperative complications. We performed a new limited resection that included total resection of the caudate lobe and anterior segment (ventral region of the right paramedian sector), and bile duct resection with hepaticojejunostomy in 3 patients with hilar cholangiocarcinoma that had not infiltrated the hepatic artery or portal vein. In all 3 patients, curative surgical resections were obtained and no serious complications were encountered. This new limited resection based on a reclassification of the liver may offer an effective procedure in limited patients with hilar cholangiocarcinoma.

Renal cell carcinoma with unusual metastasis to the gallbladder.

Gallbladder involvement in patients with renal cell carcinoma (RCC) is extremely rare. We present a report of a 61-year-old man with a synchronous RCC metastasis to the gallbladder presenting as an intraluminal polypoid mass simulating primary gallbladder carcinoma. Enhanced abdominal computed tomography demonstrated a well-enhanced polypoid lesion in the gallbladder. Intraoperative rapid pathological examination of the gallbladder tumor showed clear cell-type cancerous cells. Microscopically, tumor cells of both the resected kidney and gallbladder had round uniform nuclei, clear cytoplasm, and well-defined cytoplasmic borders, forming alveolar patterns. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) and carcinoembryonic antigen (CEA), which is usually positive in primary clear cell carcinoma of the gallbladder. Therefore, the final diagnosis was RCC with a synchronous gallbladder metastasis.

[Usefulness of image-navigated surgery in liver surgery].

Previously, computed tomography (CT) yielded cross-sectional images reconstructed from single-slice CT. However, the recently developed multidetector-row spiral CT provides isotropic voxel data sets, giving clear and precise three-dimensional images of the intrahepatic vascular structure. The vascular anatomy of the liver and relationship between liver tumors and intrahepatic vascular structure can thus be determined. We have developed software for an image-navigated surgery system with which vessels supplying blood to tumors and main hepatic vein drainage can be identified in patients preoperatively. Virtual liver resection can then be performed on a computer using this software. This simulation surgery contributes to making subsequent actual hepatic resection safer and less invasive.

Intersegmental arterial communication between the medial and left lateral segments of the liver.

BACKGROUND/AIMS: Although the interlobar arterial collateral of the liver has been thoroughly analyzed, few reports have described the intersegmental arterial collateral between the medial and left lateral segments. METHODS: The hepatic arterial system of the left liver was evaluated using 12 latex resin cast specimens in which latex resin was injected into the left hepatic artery after ligation of the right hepatic artery. RESULTS: In all 12 livers, an intersegmental collateral between the medial and left lateral segments was detected. These collaterals were extrahepatically located in the umbilical plate and gave rise to branches traveling to the bile duct of the left liver. CONCLUSIONS: The present study showed that the communicating arcade between the middle and left lateral hepatic arteries was consistently present in the umbilical plate and played an important role not only in the intersegmental arterial collateral system of the left liver but also in the blood supply to the bile ducts.

Pancreas-sparing duodenectomy for duodenal neoplasms including malignancies.

BACKGROUND/AIMS: Pancreas-sparing duodenectomy (PSD) represents an attractive operation for benign or premalignant duodenal disease. However, use of PSD is controversial for indications that include malignancy. METHODOLOGY: The present study investigated 16 patients who underwent PSD for duodenal neoplasms including adenoma, cancer, carcinoid and non-epithelial tumor. Indications for PSD were divided into 3 categories: early stage neoplasms; isolated duodenal neoplasms in high-risk patients; and duodenal involvement from adjacent organ malignancies. This study classified PSD into 4 types based on the resected portion of the duodenum, as used in gastrectomy (total, subtotal, distal, and proximal) and we experienced pancreas-sparing proximal duodenectomy and pancreas-sparing distal duodenectomy. RESULTS: Pancreatic fistula or anastomotic leak occurred in 2 patients, and were closed with nonoperative management. Although 1 patient with gallbladder cancer died postoperatively due to the results of a concomitant operation, no postoperative deaths or re-operations related to PSD were encountered. Mean duration of follow-up was 65 months. Three patients died as a result of distant metastases from primary cancer without local recurrence, and 2 patients died from other causes. The remaining 10 patients are well, with no symptoms related to the hepatobiliary and pancreatic systems. CONCLUSIONS: Good results after long-term follow-up suggest that PSD represents an attractive option for duodenal neoplasms. Moreover, absence of local recurrence suggests that PSD may also be acceptable for selected duodenal malignancies.

Sarcomatous hepatocellular carcinoma without previous anticancer therapy.

Sarcomatous hepatocellular carcinoma is a rare neoplasm of the liver. A 79-year-old man with a liver tumor was admitted to our hospital. Enhanced computed tomography and magnetic resonance imaging revealed a cystlike lesion, whereas abdominal ultrasonography revealed a solid tumor. The patient underwent medial segmentectomy of the liver for the presumptive diagnosis of atypical hepatocellular carcinoma. Microscopically, the tumor was diagnosed as hepatocellular carcinoma with sarcomatous change. Although anticancer therapy is presumed to be a cause of sarcomatous change in hepatocellular carcinoma, some cases in which patients had not previously undergone anticancer therapy have been reported. Here we report a case of sarcomatous hepatocellular carcinoma without previous anticancer therapy and present a review of the literature.

Relationship between right portal and biliary systems based on reclassification of the liver.

BACKGROUND: Although the anatomy of the right portal and biliary systems and their interrelationships must be understood to safely and satisfactorily perform left-sided resection of hilar cholangiocarcinoma or right-lobe living donor liver transplantation, the anatomies of the right portal and biliary systems are extremely difficult to understand. METHODS: A total of 60 patients with normal liver underwent computed tomography during both portography and cholangiography to evaluate relationships between the right biliary and portal systems based on reclassification of the liver to divide the right liver into 3 segments. RESULTS: All ventral and posterior ducts constantly join medially to the anterior portal trunk. In contrast, some dorsal ducts join the ventral duct medially and others join the posterior duct lateral to the anterior trunk. CONCLUSIONS: Reclassification of the liver to divide the right liver into 3 segments facilitates an understanding of relationships between the right portal and biliary systems.

Preferable operative age of choledochal dilation types to prevent patients with pancreaticobiliary maljunction from developing biliary tract carcinogenesis.

BACKGROUND: Pancreaticobiliary maljunction (PBM), which frequently accompanies choledochal dilation, is a high risk factor for biliary tract (gallbladder, bile duct) carcinoma because of the continuous reflux of pancreatic juice into the biliary tract. The aim of this study was to clarify the preferable operative age in PBM patients for the prevention of biliary tract carcinogenesis, with reference to the dilation types of bile ducts. METHODS: There were 165 PBM patients in total studied, including 92 pediatric patients (< or =15 y) (cystic, 63; spindle-like, 29; nondilation, 0) and 73 adult patients (>15 y) (cystic, 45; spindle-like, 18; nondilation, 10) who underwent operative excision of extrahepatic bile ducts or cholecystectomy. We investigated incidence by age of biliary tract malignancies and the risk according to types of dilation. RESULTS: In the pediatric group, no carcinoma case could be found preoperatively or postoperatively (mean follow-up period, 11.7 y). In the adult group, bile duct carcinomas could be detected in 6 cases of a cystic type (6 of 45; 13.3%) (3 preoperative, 3 postoperative). Among the bile duct carcinoma cases, the youngest patient was a 21-year-old woman who had undergone excision of an extrahepatic bile duct 3 years previously. Gallbladder carcinomas were detected in 16 patients: 3 of 45 cystic (6.7%), 6 of 18 spindle-like (33.3%), and 8 of 10 nondilation (80.0%), in whom the youngest patient was a 41-year-old woman with a spindle-like type. CONCLUSIONS: To prevent biliary tract carcinogenesis in PBM patients, cystic-dilated choledochus should be excised in childhood before the development to a precancerous stage. In spindle-like and nondilation types, cholecystectomy is absolutely necessary in early adulthood before age 40.

[A case regarded as an occult breast cancer treated without mastectomy].

A 51-year-old woman was admitted to our hospital with a chief complaint of left axillary tumors. No such tumors were detected in bilateral breasts by ultrasonic tomography, mammography, computed tomography, and magnetic resonance imaging. The core needle biopsy from the left axillary lymph node was examined, and the specimen revealed an occult breast cancer, because the microscopic findings resembled the breast cancer organization and immunochemistry revealed positivity of the estrogen receptor. The radical left axillary dissection was operated. Tamoxifen and FEC 100 6 cycles were selected as adjuvant treatment. At one year after operation, she has no recurrence. Carcinoma cells had portedly been recognized in the mammary gland with 82.7% of the cases who had undergone mastectomy for occult breast cancer. However, in many cases, the patient's consent for mastectomy was not obtained like as in this case, and the choice of treatment is often difficult. We considered that the case's accumulation was necessary to verify the possibility of the mastectomy omission to an occult breast cancer, presented the case report.

Proposal for a reclassification of liver based anatomy on portal ramifications.

BACKGROUND: Portal branching patterns that differ from those previously described are occasionally encountered during liver surgery. METHODS: A total of 60 patients with normal intrahepatic venous anatomy underwent helical computed tomography during arterial portography (CTAP). Next, 3 dimensional portograms were reconstructed to verify the locations of the portal veins. Portal branching patterns in the right hemiliver were assessed. RESULTS: In all 60 patients examined, the right anterior portal vein bifurcated into the ventral and dorsal branches. In 42 (70%) of 60 patients, some branches arose from the right posterior portal trunk. Between 1 and 3 branches (mean 2.3 branches per patient) coursed cranially, between 2 and 5 branches (mean 3.2 branches per patient) coursed caudally, and between 1 and 2 branches (mean 1.3 branches per patient) coursed laterally. CONCLUSIONS: We propose that the right liver should be divided into 3 segments, which are designated as the right anterior, middle, and posterior segments.

Hepatoblastoma in an adult A case report and clinical review of literatures.

In this paper, our aim is to report a very rare case of adult hepatoblastoma (HB) and to discover clues of diagnosis and adequate treatment by surveying collected English literatures. Our patient was a 20-year-old lady suffering from nausea and appetite loss. The main tumor measuring 18cm was located in the anterior and medial segments. Other tumors were also present in the left lobe. The tumors had cystic areas and hypervascularity. The chemotherapy based on the diagnosis of HCC by needle biopsy had failed. The tumors were resected together with the diaphragm and diagnosed as adult HB of epithelial type. The patient succumbed to cancer 3 months later. We have collected 25 cases of adult HB and discussed clinical features. Diagnostic findings are as follows: single huge tumor, located in the right lobe, having cystic change, calcification (mixed type) and hypervascularity. Preoperative needle cytology or biopsy failed to diagnose all but one case. All living cases were resected without preoperative chemotherapy. No response to chemotherapy was observed in any case. If a tumor has the above clinical features, we have concluded that an excision of the tumor should be considered, without preoperative chemotherapy and tumor puncture.

Anterior fissure of the right liver--the third door of the liver.

BACKGROUND/PURPOSE: Although the anterior segment of the liver has been divided into segments 8 and 5, we have, during surgical or interventional procedures, occasionally encountered patients in whom the right anterior portal vein does not bifurcate into the superior and inferior branches. Thus, the in vivo anatomy of the right liver was reevaluated to clarify the segmental anatomy. METHODS: We evaluated the hepatic venous and portal ramification patterns, using three-dimensional images reconstructed from computed tomography. In addition, liver volumetry was performed. RESULTS: All branches arising from the anterior trunk were divided into two groups: the right ventral portal branches (RVP) and the right dorsal portal branches (RDP), and the anterior fissure vein crossed between the RVP and RDP. The ventral and dorsal regions of the anterior segment were approximately equal from a volumetric point of view. CONCLUSIONS: The anterior segment seems to be divided into the ventral and dorsal segments by the anterior fissure, and we propose a reclassification of the right liver that divides the right liver into three segments. Dissection of the parenchyma along the anterior fissure makes the third door of the liver open, resulting in the exposing of all Glissonian pedicles of the right liver. The introduction of our segmental anatomy and surgical procedure will allow more systematic and limited liver resections.

Prognostic factors for hepatocellular carcinoma presenting with macroscopic portal vein tumor thrombus.

BACKGROUND/AIMS: This study examines the prognostic factors including radiological findings of hepatocellular carcinoma presenting with macroscopic portal vein tumor thrombus. METHODOLOGY: From September 1992 to December 2002, 107 patients with hepatocellular carcinoma and a macroscopic portal vein tumor thrombus were treated at the National Cancer Center Hospital East. Patients' characteristics and diagnostic findings of computed tomography, angiography and computed tomography angiography were analyzed to determine the factors significantly related to the patients' prognosis. RESULTS: Enhanced portal vein tumor thrombus, main tumor occupying over 40% of the liver and distribution of tumors significantly affected survival. Cavernous transformation, thread and streak signs, arterio-portal shunt, extent of tumor thrombus, grade of venous invasion and tumor size did not affect survival. Clinical findings showed that Child-Pugh classification score over 7, etiology of hepatitis, total bilirubin over 2.2 mg/dL, prothrombin time under 50% and liver transaminases over 100 IU/L were poor prognostic factors. Multivariate analysis showed that AST over 100 IU/L, viral hepatitis and tumor occupying over 40% of the liver strongly affected the prognosis. CONCLUSIONS: Based on the present results, the most strongly affected prognostic factor was liver function as indicated by high level of transaminases. Various radiological findings did not affect survival. The elevation of transaminases seemed due to destruction of hepatocytes by growing tumor and circulatory disruption due to portal vein tumor thrombus. We concluded that radiological findings of hepatocellular carcinoma presenting with portal vein tumor thrombus indicated only intrahepatic status but not survival. First treatment for hepatocellular carcinoma presenting with portal vein tumor thrombus should be to improve the liver function. Treatment against hepatitis virus might be important and patients with AST over 100 IU/L and a tumor occupying over 40% should not undergo surgical resection.

Role of curative resection in octogenarians with malignancy.

BACKGROUND: Major resective surgery in octogenarians with malignancy is considered risky. Because elderly people are growing in number, there is a greater need to define the role of curative resection (CR) in these patients. METHODS: In this retrospective, consecutive review patients > or = 80 years with malignancy treated by surgery were included and categorized into 3 groups: group 1 = CR group, i.e., no residual disease; group 2 = non-CR group, i.e., microscopic tumor invasion of one or more resection margins; and group 3 = palliative surgery (PS) group. RESULTS: One hundred eighty-two patients were treated surgically with curative intent. Gastric and colorectal cancers were the most frequent (34% and 31.8%, respectively) followed by bile duct and esophageal cancers (15.3% and 5.5%, respectively). CR was performed in 53.3%, non-CR in 14.8%, and palliative surgery in 31.9% of patients. Thirty-day mortality in the 3 groups was 3.1%, 0%, and 5.2%, respectively. Mean hospital stay was similar among all 3 groups. In the CR group, gastric and colorectal cancers were the most common (41.2% and 42.2% respectively). Average survival and actuarial survival were significantly higher in the CR group. Disease-free survival was 645 +/- 744 days. Five-year actuarial survival was 45.4 % in the CR group, and no patient survived 5 years in the other 2 groups. In the CR group, mean survival was significantly better in patients with good performance status and > or = 3 supportive family members per univariate analysis. However, no significant difference was observed in patients with gastric and colorectal malignancy. Multivariate analysis revealed that TNM stage and family size affected survival the most. CONCLUSIONS: Gastric and colorectal cancers were most frequent among octogenarians reporting to our unit. CR was performed in elderly patients with low mortality and was associated with significantly better average and actuarial survival. TNM stage I to III, family size > or = 3 members, and performance status "0" to "1" were favorable factors.

Limited resection of the right hemiliver based on reclassification of the right anterior segment of the liver.

We proposed that the anterior segment was divided into ventral and dorsal segments, and reclassified the right hemiliver into three segments; ventral, dorsal, and posterior segments. According to our classification we successfully performed limited resection of the right hemiliver.

Limited resection based on reclassification of segment 8 of the liver.

Liver vein patterns which differ from those previously described are occasionally encountered during surgery. Therefore, we reclassified the anterosuperior segment (S8) into S8v (ventral area) and S8d (dorsal area), and the right paramedian sector into the ventral segment (S8v+S5) and the dorsal segment (S8d) based on portal and hepatic vein patterns. Using this new classification, we performed three types of limited resection of S8 in six patients with neither major nor minor procedural complications including biliary leaks, and no blood transfusion. This new classification allows development of surgical procedures where resection is limited to the portal unit and tumor.

Relation between hepatic and portal veins in the right paramedian sector: proposal for anatomical reclassification of the liver.

Although a right liver graft without a middle hepatic vein resulted in potential venous congestion in the right paramedian sector, the details of the hepatic venous distribution in the right paramedian sector have not been established. In this study, the ramification patterns of the hepatic veins draining the right anterosuperior segment (S8) and the relation between the hepatic and portal veins were assessed using multislice computed tomography in 44 patients without lesions in the liver. All 52 drainage veins of the ventral area of S8 joined the middle hepatic vein, and all 48 drainage veins of the dorsal area joined the right hepatic vein. The hepatic vein crossing between the ventral and dorsal areas was observed in each patient examined. Therefore, we propose a reclassification wherein the right paramedian sector is divided into ventral and dorsal segments. This new classification may contribute to the development of new and safer surgical procedures, including more limited resection and right lobe adult living donor liver transplantation to avoid graft congestion.